Treatment of Comminuted Distal Radius Fracture in a 70-Year-Old with Dementia
A six-week short-arm cast is appropriate for this 70-year-old patient with dementia, as non-operative treatment in geriatric patients (≥65 years) achieves equivalent long-term functional outcomes to surgery, and a short-arm cast provides adequate stability while minimizing complications and restrictions on daily activities.
Age-Based Treatment Approach
The American Academy of Orthopaedic Surgeons provides strong evidence that surgical fixation in patients above 65 years does not lead to improved long-term patient-reported outcomes compared to non-operative treatment, despite better radiographic parameters with surgery 1.
This recommendation is based on two high-quality studies and 11 moderate-quality studies demonstrating no difference in functional outcomes between operative and non-operative management in geriatric patients 1.
Age 65 serves as a proxy for functional demand, and in a patient with dementia, functional demands are typically lower, further supporting conservative management 1.
Short-Arm vs Long-Arm Cast Selection
A short-arm cast is specifically appropriate for this patient and offers advantages over a long-arm cast:
A prospective randomized multicentre study in patients over 55 years with stable distal radius fractures demonstrated that short-arm casts are as effective as long-arm casts for radiological and functional outcomes 2.
Short-arm casts result in significantly lower disability scores, less shoulder pain, and fewer restrictions on daily activities compared to long-arm casts 2.
In patients with dementia, the reduced restriction and improved comfort of a short-arm cast may improve compliance and reduce agitation 2.
Duration of Immobilization
Six weeks of immobilization is appropriate, though emerging evidence suggests shorter durations may be considered:
Traditional treatment protocols use 5-6 weeks of cast immobilization for displaced distal radius fractures in elderly patients 3, 4.
A 2023 randomized controlled trial demonstrated that four weeks of immobilization produces similar functional outcomes (PRWE and QuickDASH scores) and complication rates compared to six weeks in displaced fractures 5.
A 2024 systematic review concluded that displaced and reduced distal radius fractures should not be immobilized shorter than 4 weeks due to complication risk, but 4-6 weeks is the optimal range 6.
Given the comminuted nature and dorsal angulation in this case, the traditional 6-week duration is prudent to ensure adequate healing and prevent loss of reduction 3.
Critical Management Considerations for Dementia Patients
Special attention must be paid to this patient's dementia:
Ensure finger motion is never restricted during cast treatment, as this increases stiffness risk without improving fracture stability 7.
Active finger motion exercises should be initiated immediately to prevent stiffness 7, 8.
Monitor for cast-related complications (skin irritation, pressure sores), which occur in approximately 14.7% of immobilized patients and may be higher in patients with dementia who cannot reliably report discomfort 8, 9.
Consider caregiver education regarding cast care and monitoring, as the patient may not recognize or communicate problems due to cognitive impairment.
Radiographic Monitoring
Obtain radiographs at approximately 1 week post-reduction to detect early loss of reduction 7.
Continue radiographic monitoring at 3 weeks and at cast removal 7, 9.
The frequency of radiographic follow-up does not significantly impact outcomes, so clinical judgment should guide additional imaging if new symptoms develop 1.
Common Pitfalls to Avoid
Do not pursue surgery based solely on radiographic parameters (dorsal angulation, comminution) in this geriatric patient, as functional outcomes will not improve despite better radiographic appearance 1.
Do not restrict finger motion at any point during treatment—this is a critical error that increases stiffness without benefit 7.
Do not default to a long-arm cast thinking it provides better stability; it only increases patient discomfort and complications without improving outcomes in stable fractures 2.
In patients with dementia, be vigilant for cast-related complications that may go unreported due to communication difficulties.
Expected Outcomes
Conservatively treated elderly patients with distal radius fractures typically return to baseline range of motion, grip strength, and functional scores by 12 months 4.
Objective outcome measures continue to improve between 6 and 12 months post-injury 4.
The majority of patients treated non-operatively recover fully after minimally to moderately displaced distal radius fractures 4.